Analysis Chain of Events With the loss of the Manson and both crew members, the exact sequence of events leading up to the vessel's capsizing and loss could not be determined. At about 0301, the speed vector for the Manson/McKenzie on the MCTS radar reduced and then disappeared as the two vessels stopped to the west of the M.B.D.32. The Manson was an estimated 120m from the M.B.D.32, with the McKenzie some 75m astern. By 0302, the Manson had lost steering, and at 0305, it stopped between the two barges to investigate the steering failure. Following the 0305 communication with the MCTS, the crew's attention was focussed on determining the cause of steering failure. Because access to the engine room and lazarette was through hatches in the main deck, both crew members would be away from the wheelhouse. The latter could account for the MCTS experiencing difficulty in raising the Manson and the developing dangerous situation going unnoticed. Additionally, the floodlights on deck used to illuminate the work area in conjunction with rain on a dark night would have impaired the crew's vision and hampered their ability to detect the movement of the barge relative to the tug's position. With the vessels tethered by some 75m of tow wire, southeasterly seas and the 25-knot southeasterly winds acting on the larger sail area of the McKenzie, the McKenzie would have drifted downwind in a northwesterly direction more quickly than the Manson. This difference in the rate of drift would cause the tow wire to become taut, possibly with a jerk or jarring motion, and would result in the tug eventually being dragged sideways until it was placed in irons.3 This in turn would cause the tug to heel over quickly, taking on water and downflooding into the lower compartments through the open hatchways and/or the open deckhouse door. The vessel would then eventually lose all reserve buoyancy and sink. The precise reason why the Manson was not found attached to the tow wire could not be established. However, the activation of the abort mechanism by the crew at a late stage or the weight associated with the sinking of the tug are possible explanations. Safe Crewing The vessel's SIC was endorsed for a crew of four, including the master. It was recognized that there would be two watchkeeping crew standing 12-hour watches while the other two crew members would be off watch. The Manson did not have a regular work cycle and frequently operated in and around Vancouver Harbour and the Fraser River for a duty cycle of 12hours or less. It was therefore customary for the off-watch crew to remain ashore. This sea passage was undertaken in darkness and would have exceeded 12hours between ports. Additionally, during adverse weather, the crew members were challenged by the loss of a barge and steering failure. When their workload increased, there was insufficient crew to handle the emergency. This led to the development of the dangerous situation and deprived the crew of timely important information to initiate corrective measures before capsizing. Emergency Beacon Database After the Manson capsized, its 406MHz EPIRB deployed and functioned as designed. Its identifier signal was relayed via satellite and routed to the JRCC in Esquimalt, British Columbia. The Canadian Beacon Registry contains information about the beacon, the vessel it is on, and the vessel owners. To keep registry information current, EPIRB owners are required to report ownership changes; this was not done for the Manson. Due to the large number of false EPIRB (distress) alerts, it is necessary to validate a distress signal before tasking valuable and appropriate SAR resources. Information available indicates that many SAR centres, with increasing frequency, are encountering instances where the emergency beacon database information has not been updated or is inaccurate. The successful outcome of a SAR mission depends upon timely, accurate, and pertinent information, which includes the vessel's position. A delay in obtaining this information may compromise appropriate and timely deployment of SAR resources. In this instance, because of .prior communications and radar information available to MCTS, validating the distress signal by establishing contact with the new owner was not critical. However, in other cases, valuable rescue time may be lost validating the distress signal. Connection of Tugs and Tows To ensure safe passage during a marine towing operation, the gear used to connect a tug with its barge(s) needs to be strong, yet flexible enough to withstand the forces likely to be encountered during a voyage. As control over the tow is paramount when towing in sheltered waters, such as a harbour or river, it is a common practice to use couplers for towing operations. However, in exposed waters where changing wave height and frequency- such as in typical rough November waters- are likely to place a greater stress on the towing equipment, it is essential that the towing gear be robust and long enough to absorb shock. The catenary in the long tow wire increases the wire's ability to withstand shock absorptions associated with severe weather and environmental conditions. For this reason, in exposed waters, an all-wire towing arrangement is the preferred mode for towing. In this occurrence, when connecting the M.B.D.32 to the McKenzie for the tow across the Strait of Georgia in November- a time when rough weather and sea conditions are to be expected- short, synthetic-rope couplers were used instead of a longer, more robust wire arrangement that would have been better suited to the conditions. The towing arrangement of the Manson was configured with a wire pendant so that an all-wire option was available to the crew; it is not known why the crew members chose to use shorter, synthetic-rope couplers. Records for Towing Equipment Neither the owner nor the vessel had a structured approach to examine, record, evaluate, and make informed decisions on the renewal/replacement of towing gear. Cargo gear or anchors and cables used on board vessels are required to be clearly identified, marked, tested and certificated on a periodic basis. This, together with routine inspection, examination and maintenance information, is required to be recorded in a register. This is essential to ensure that critical components on board the vessel are inspected, serviced and retired before they fail to reduce risk of human injury. Although the risk posed by towing gear is equally high, similar practices are not universally embraced in the towing industry. The Manson's inspection certificate stipulated a crew of four, but only two persons were on board for this passage. It is likely that the under-crewing of the Manson permitted a developing dangerous situation, which culminated in the tug's capsizing to go unnoticed. The inappropriate towing arrangement- shorter, synthetic-rope couplers instead of a longer, all-wire arrangement- used for towing in open waters resulted in the couplers parting and the M.B.D.32 becoming adrift, precipitating the onset of an emergency situation. The failure of the steering gear- the cause for which could not be ascertained- occurred at a critical time in the vessel's operation.Findings as to Causes and Contributing Factors The Manson's inspection certificate stipulated a crew of four, but only two persons were on board for this passage. It is likely that the under-crewing of the Manson permitted a developing dangerous situation, which culminated in the tug's capsizing to go unnoticed. The inappropriate towing arrangement- shorter, synthetic-rope couplers instead of a longer, all-wire arrangement- used for towing in open waters resulted in the couplers parting and the M.B.D.32 becoming adrift, precipitating the onset of an emergency situation. The failure of the steering gear- the cause for which could not be ascertained- occurred at a critical time in the vessel's operation. The Canadian Beacon Registry is not always notified when emergency position indicating radio beacons (EPIRBs) are purchased or when a vessel's ownership changes, resulting in database inaccuracies. Valuable time lost in obtaining information related to search and rescue (SAR) compromises appropriate and timely deployment of SAR resources. Although the risks and consequences of towing gear failure are high, there is no regulatory requirement or industry standard for record-keeping and maintenance of towing gear similar to that required for cargo gear.Findings as to Risks The Canadian Beacon Registry is not always notified when emergency position indicating radio beacons (EPIRBs) are purchased or when a vessel's ownership changes, resulting in database inaccuracies. Valuable time lost in obtaining information related to search and rescue (SAR) compromises appropriate and timely deployment of SAR resources. Although the risks and consequences of towing gear failure are high, there is no regulatory requirement or industry standard for record-keeping and maintenance of towing gear similar to that required for cargo gear. The Marine Communications and Traffic Services (MCTS) watch officer's vigilance resulted in initiating action that recovered the drifting barge, and the officer's close monitoring of the developing situation led to timely SAR action.Other Finding The Marine Communications and Traffic Services (MCTS) watch officer's vigilance resulted in initiating action that recovered the drifting barge, and the officer's close monitoring of the developing situation led to timely SAR action. The industry has taken action to address the problems associated with the Canadian Beacon Registry database. The Council of Marine Carriers (CMC), representing the regional towing community, and the B.C. Seafood Alliance, representing the fishing community, have informed their memberships to ensure that emergency position indicating radio beacons (EPIRBs) are properly registered. The National Search and Rescue Secretariat (NSS) has established communication with Transport Canada (TC) Ship Registration Office to develop a method of advising vessel owners to update the NSS database when changes are made to the vessel's registry. Following a series of tug/barge occurrences in 2004, TCconvened an internal tug/barge task force, mandated to develop guidance relating to tug/barge combinations, and provide recommendations to the Regulatory Reform team on amendments to related regulations. In December 2005, the task force submitted a report that recommended, inter alia, that mooring winches, tow cut-offs, cables, chains and towlines on tugs and barges should be recognized as ship's equipment and be properly examined and documented. Furthermore, at the Canadian Marine Advisory Coucil (CMAC) November 2006 meeting, a tug/barge working group was formed with participation from 13marine industry organizations, labour unions, and TC. Consideration is being given to creating a CMAC standing committee to deal solely with tug/barge issues.Safety Action Taken The industry has taken action to address the problems associated with the Canadian Beacon Registry database. The Council of Marine Carriers (CMC), representing the regional towing community, and the B.C. Seafood Alliance, representing the fishing community, have informed their memberships to ensure that emergency position indicating radio beacons (EPIRBs) are properly registered. The National Search and Rescue Secretariat (NSS) has established communication with Transport Canada (TC) Ship Registration Office to develop a method of advising vessel owners to update the NSS database when changes are made to the vessel's registry. Following a series of tug/barge occurrences in 2004, TCconvened an internal tug/barge task force, mandated to develop guidance relating to tug/barge combinations, and provide recommendations to the Regulatory Reform team on amendments to related regulations. In December 2005, the task force submitted a report that recommended, inter alia, that mooring winches, tow cut-offs, cables, chains and towlines on tugs and barges should be recognized as ship's equipment and be properly examined and documented. Furthermore, at the Canadian Marine Advisory Coucil (CMAC) November 2006 meeting, a tug/barge working group was formed with participation from 13marine industry organizations, labour unions, and TC. Consideration is being given to creating a CMAC standing committee to deal solely with tug/barge issues.